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Summer School Application Form
Date
Student Name
Date of Birth
Student's Current Grade
Parent/Guardian Name
Phone
--
Email
Emergency Information
Contact Name
Relationship
Phone#
Medical Information
Physician Name
Phone#
Allergies
Does student have an IEP
Yes
No
Type of Summer Study
Remedial Study
Art
Foreign Language
Music
Sports
Program Options
Which session are you interested in?
Session I - June
Session II - July
Session III - August
Signature

Physician Name	Phone#	Allergies

Summer School Application Form